Transcript Rheumatology Revision

Rheumatology Revision
Everything you need to know in one hour!
Likely exam situations
•
Rheumatology History
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Hand examination (knee, ankle and foot)
•
Common Rheumatology referrals
•
•
Back pain- prevalence, approach to Ix and Mx,
differentiating inflammatory vs non-inflammatory
•
Connective Tissue Diseases
Rheumatology Emergencies- septic joint, vasculitis,
lupus flare.
A quick reminder of joint
names
History taking

Presenting Complaint
 Pain
- SOCRATES
 Arthritis

Inflammatory or non-inflammatory

Redness, heat, swelling, early morning stiffness

Symmetrical or asymmetrical

Mono/oligo/polyarthritis
 Associated

features
RA: Raynaud’s, fever, malaise, chest symptoms, dry
eyes and mouth

Seronegative: red sore eyes, back pain, rash,
diarrhoea

CTD: same as RA + consider alopecia, muscle
pain/weakness, difficulty swallowing, rash
 Osteoporosis
risk factors
 Fibromyalgia

Sleep pattern

Associated conditions – IBS, migraine


PMH

Any arthritic conditions

Any autoimmune conditions (thyroid disease most common)

Inflammatory bowel disease

Psoriasis
DH

In a patient with a known diagnosis of inflammatory arthritis, take
a full DMARD hx

Think about diuretics and antihypertensives if suspecting gout



FH

Same as for PMH

Maternal hip fracture for osteoporosis
SH

Cigarettes and alcohol

Functional status at home and at work
System Enquiry
Joint pain
Arthritis
Inflammatory
Arthritis
Metabolic
Non inflammatory
Arthritis
Vitamin D
Paget’s
Osteoporosis
Soft Tissue
Rheumatism
Fibromyalgia
Regional Pain
syndromes
Fibromyalgia
Middle aged women
Widespread myalgias and arthralgias
Trigger points
Associated sleep disturbance
Also associated with…
IBS
Migraine
Depression and anxiety
Chronic fatigue syndrome (part of a
spectrum)
A DIAGNOSIS OF EXCLUSION!
Osteoarthritis
•
Classification
•
By site
•
By cause
•
By features
•
Risk factors
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Obesity, sex,
genetics,
hypermobility
•
Trauma,
inflammation, sepsis,
AVN, slipped
epiphysis, obesity,
occupation
Osteoarthritis –
clinical features
•Hand
Heberden’s (DIPJ) and
Bouchard’s (PIPJ) nodes
1st CMC squaring
Generalised wasting
•Knee:
Quadriceps wasting
Crepitus
Cool effusion
Valgus/varus deformity
Instability
•Hip:
Reduced rotation (internal)
Trendelenburg +
Osteoarthritis – X-rays

Sclerosis

Osteophytes

Loss of joint space

Cysts
Osteoarthritis - treatment



Lifestyle modification
(weight, exercise)

Drugs

Simple analgesia

NSAIDs – be aware of
side effects

COX-2 inhibitors –
controversy about
cardiovascular sideeffects

Glucosamine –
controversy whether it
works. Great placebo
effect!
Footwear
Physiotherapy

Quadriceps exercises

Occupational therapy

Complementary therapies

Intra-articular steroid

Which of the following statements regarding
rheumatoid arthritis is correct?
A. A negative anti CCP antibody confers a worse
prognosis
B. Rheumatoid nodules only occur in seropositive
disease
C. Men are affected more frequently than women
D. 1 in 1000 of the population are affected
E. Prednisolone is the first line therapy
Rheumatoid Arthritis

Symmetrical inflammatory polyarthritis

Propensity to affect small joints

+ve rheumatoid factor (80-90%)

Rheumatoid nodules

1% of adult population

Female to male 3:1

Peak onset age 35-45
Chronic Inflammation in the
Rheumatoid Synovium
Activated T cells
Macrophage
Pannus
PMN
B cell
Cytokine
Inflamed
synovial membrane
Bone
Eroding cartilage
RA – extra-articular problems

Raynaud’s

Sicca syndrome



Pericarditis
Pleuritis/
Pulmonary Fibrosis
Subcutaneous
Nodules

Ocular
Inflammation

Neuropathies

Vasculitis

Increased
cardiovascular risk
Goals of Therapy in RA





Induce remission
Reduce pain and inflammation
Improve physical function
Retard/halt joint destruction
Improve survival
Primer on the Rheumatic Diseases. 12th ed. Atlanta, Ga:
The Arthritis Foundation; 2001: 225-231.
RA - treatment
Anti TNF drugs

Physiotherapy

Occupational
therapy

Etanercept
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Adalimumab
DMARDs
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Certolizomab
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 Methotrexate

B cell inhibitors
 Sulfasalazine
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T cell co stimulator
inhibitors

IL6 inhibitors
 Gold

RA hands 1
Look

Typical rheumatoid deformities

Joint swelling,subluxation, swan neck, Boutonniere’s, ulnar
deviation

Muscle wasting

Rheumatoid nodules (remember elbows)

Rash

Palmar erythema

Purpura (and skin thinning) 2ndary to steroids

Livedo reticularis / skin mottling (associated with Raynaud’s)
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Nailfold infarcts / splinter haemorrhages (rheumatoid vasculitis)
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Feel


Is the arthritis active?
Move


RA hands
2
Assess function

Grip strength

Writing

Buttons
Other bits

Consider further muscle and neurological assessment
OA hands


Look

Heberden’s nodes

Bouchard’s nodes

Squaring of hand (OA of 1st CMCJ)

Check elbows (you shouldn’t see anything!)
Feel


Is there active inflammation?
Move

Assess function
Your final statement
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Come up with a diagnosis

Explain how you got to the diagnosis

Comment on function
Seronegative inflammatory
arthritis

Asymmetrical inflammatory oligoarthritis

Tends to affect large joints

HLA B27 +ve

Distinctive features
 Sacroiliitis
 Dactylitis
 Uveitis
Sero –ve subtypes (RAPE)


Reactive

Post infection, esp diarrhoea or STD

Reiter’s classic triad of arthritis, urethritis and uveitis
Ankylosing
spondylitis

Classically young men with inflammatory back pain

Can also get peripheral arthritis
RAPE continued


Psoriatic
arthritis
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Can develop before onset of psoriasis

5 different patterns (oligoarticular, RA-like, sacroiliitis,
DIPJ and nail involvement only, arthritis mutilans)
Enteropathic

arthritides
Associated with inflammatory bowel disease
Crystal Arthritides

Gout
•
Inflammatory response to monosodium urate
monohydrate crystals (needle shaped,
negatively birefringent)
•
Associations: age, sex, alcohol, hypertension,
renal impairment, diuretics
 Acute

Rapid onset

90% monoarticular

1st MTPJ in >50% of first attacks

Usually settles within 7-10 days
 Chronic

Gouty tophi

Urate nephropathy
Urate
More crystal arthritides

Pseudogout
 Calcium
pyrophosphate crystal deposition in joints
(rhomboid positively birefringent)
 Mainly
 Acute
elderly, F>M, ubiquitous
self-limiting synovitis
 Chronic
arthropathy strong assoc / overlap with OA
Pyrophosphate
Septic Arthritis

Predisposing factors
 immunosuppression
 pre-existing
 iv
joint damage
drug abusers
 age
 indwelling
catheters

80% monoarthritis, 20% oligo or polyarthritis

S. aureus, gram –ve organisms, Neisseria gonorrhoeae
Connective Tissue Diseases

Rheumatoid arthritis

SLE

Sjogren’s

Scleroderma

Polymyositis

Dermatomyositis

Polyarteritis Nodosa

Wegener’s Granulomatosis
Connective tissue diseases

Common factors
 Raynaud’s
 General
 ANA
malaise
+ve
 Raised
inflammatory markers
 Secondary
 Lung
Sjögren’s
fibrosis
Autoantibodies
RA
Rheumatoid factor
SLE
ANA, dsDNA, antiphospholipid
antibodies (anticardiolipin, lupus
anticoagulant)
SSc
Anticentromere antibody (limited)
Scl-70 (diffuse)
Myositis
Anti-Jo-1
Wegener’s
ANCA
Sjogren’s
Anti-Ro, Anti-La (part of ENA)
Overlap syndromes
Anti-RNP (part of ENA)

Young women

Blacks and
Hispanics

12/100,000 in
UK
SLE – diagnostic criteria

4 out of 11 of:
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Malar rash

Discoid rash
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Photosensitivity
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Oral ulcers
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Arthritis


Serositis (pleurisy,
pericarditis, peritonitis)




proteinuria >0.5g/24h or 3+
cellular casts
Haemolytic anaemia or
low WCC (<4), low
lymphocytes (<1.5) or
low plt (<100) (at least
x 2 each)
Immunological


Seizures or psychosis
Haematological

Renal

Neurological
LE cells, or dsDNA, or
anti-Sm or false
positive VDRL
ANA
SLE – other features

Fever

General malaise and fatigue
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Weight loss
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Alopecia
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Other organ involvement
 Lungs
 Heart
(pneumonitis, pulmonary hypertension)
(myocarditis, endocarditis)
Ix

Complete blood count and differential

Comprehensive metabolic profile

Creatine kinase

Erythrocyte sedimentation rate and/or C reactive
protein

Urinalysis

Quantitation of proteinuria or protein/creatinine
ratios
Autoantibodies in SLE

ANA

dsDNA

Anti Smith (Sm)

LA, ACL

C3/C4
Systemic sclerosis
 Raynaud’s
 GI
problems

Oesophageal dysmotility

Small bowel overgrowth

Bowel failure
 Lung
fibrosis
 Primary
pulmonary hypertension
 Scleroderma
renal crisis
Limited Systemic
Sclerosis
Calcinosis
Raynaud’s
Esophageal dysmotility
Sclerodactyly
Telangiectasia


Look
Hand Exam
SSc

Skin thickening

Sclerodactyly

Telangiectasia

Calcinosis

Ulceration

Digital pitting

Note any facial features of scleroderma
Feel

Skin thickening

Degree

Extent (limited or diffuse disease)
Gottron’s papules
Polymyositis and Dermatomyositis

Inflammatory diseases of muscles +/- skin.
 PM
– muscle involvement only
 DM
– heliotrope rash, Gottron’s papules

Adults and children, 2-9 cases/million/ year

Association with malignancy
 20%

of DM, 13% of PM
Ix – EMG, MRI, muscle Bx
Vasculitides


Small

Rheumatoid vasculitis - RhF

Henoch-Schonlein purpura – rash, arthralgia, abdo pain

Wegener’s granulomatosis – ANCA – kidneys and lun
Medium


Polyarteritis nodosa
Large

Temporal arteritis – overlap with polymyalgia rheumatica

Takayasu’s arteritis
•
A 68 year old woman presents with a 6 day history of
headaches. She describes discomfort when she
combs her hair. She has also been struggling to get
dressed in the morning. There is no muscular
weakness. Blood tests reveal an ESR of 90mm/hr,
elevated alkaline phosphatase and a normal CK.
What is the most appropriate initial management?
A. Urgent CT Brain
B. Temporal artery biopsy
C. Prednisolone 15mg daily
D. Prednisolone 60mg daily
E. Analgesia and referral to an ophthalmologist
Approach to temporal arteritis

Refer Urgently but don’t delay treatment

Biopsy within 1-2 weeks

Start Prednisolone immediately
› 40-60 mg in uncomplicated disease
› IV Methylprednisolone in complicated disease
› Bone Protection , Aspirin

Follow up with rheumatologist/GP with protocol
for reducing steroids.
The Eye in Rheumatic Disease

Iritis
› HLA associated / vasculitis

Scleritis
› RA
•

very painful
Episcleritis
› RA
•
more of a nuisance
Good Luck!
If there’s time…

Feet

Knees

Shoulders
Feet
Knees
Vitamin D is a multifunctional prohormone1
Vitamin D is important for MSK health, immune system and CVS
1.Adapted fromsystem.
Dusso AS et al. Am J Physiol Renal Physiol 2005; 298(1): F8-28.
•
Effects of Vitamin D deficiency
Reduced
calcium
gut
absorption
Reduced
serum
calcium
Increased
PTH
Secondary
hyperparat
hyroidism
Phosphatu
ria
Calcium
bone
resorption
Bone
deminerali
zation
Identifying adults at risk of vitamin D deficiency in
clinical practice
Adult at risk groups1
People over 65 years of age
Thinning of the skin reduces the efficiency of
vitamin D synthesis
Inadequate sunlight
exposure
Covered skin for medical, social, cultural or
religious reasons, housebound
Non-whites
Darker skin pigments interfere with UV light
reaching the appropriate skin layer
Poor health
Low HDL, no daily milk
Obesity
Possibly related to unbalanced diet, low HDLs.
1. National Osteoporosis Society Practical Guidelines. Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. April
2013. Available at: http://www.nos.org.uk/document.doc?id=1352
2. NHANES Survey 2005-6
Manifestations and symptoms of vitamin D deficiency1
Manifestations
Deficiency
Insufficiency
Symptoms
Osteomalacia in
adults
Bone pain (ostealgia)
Rickets in children
Joint pain (arthralgia)
Secondary
hyperparathyroidism
Muscle pain (myalgia)
Bone loss
Muscle weakness
Muscle weakness
Difficulty walking
Falls and fragility
fractures in older
people
Fractures
1. National Osteoporosis Society Practical Guidelines. Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. April
2013. Available at: http://www.nos.org.uk/document.doc?id=1352